Acute Decompensated HF

Helpfulness: 0
Set Details Share
created 3 weeks ago by brandibyler
17 views
updated 11 days ago by brandibyler
show moreless
Page to share:
Embed this setcancel
COPY
code changes based on your size selection
Size:
X
Show:
1

Acute Decompensated HF is defined as pts having new or worsening symptoms of ________, ___________, _____________ where additional medical care is indicated.

  • Systemic volume overload
  • Acute pulmonary edema
  • Hypoperfusion
2

T/F: Acute Decompensated HF may have preserved or impaired LV fxn

True

3

What kind of meds could cause acute decompensated HF?

  • Anthracyclines (chemo)
  • NSAIDs, COX2i
  • Steroids
  • non-DHP CCB
4

List 10 etiology/precipitating factors of ADHF:

  1. Non-adherence to meds/diet
  2. Infection (pneumonia)
  3. HTN crisis
  4. Meds
  5. Excessive alcohol/drug use
  6. Cardiac event
  7. Pulm. embolus
  8. Endocrine dz
  9. De novo HF
  10. Severe LV systolic dysfxn w progressive worsening of CO refractory to therapy
5

List examples of cardiac events that could cause ADHF:

  • Recurrent MI
  • Myocardial ischemia
  • A fib
6

T/F: We assess ADHF with a complete hx, physical exam, and MRI to determine perfusion and volume status.

False

7

Aside from perfusion and volume status, what else is assessed for ADHF?

  • Onset, duration, severity of sx
  • Precipitating factors/comorbidities
  • New onset exacerbation of chronic dz
  • Preserved EF
  • Chest radiographs, electrocardiogram, echocardiography
8

Symptoms of pulmonary congestion:

  • Dyspnea
  • Orthopnea
  • Paroxysmal nocturnal dyspnea
  • Tachypnea
9

Signs of pulmonary congestion:

  • Rales
  • Pulmonary edema
  • Pleural effusion
  • Hypoxemia
  • 3rd heart sound (L sided) -S3 gallop
10

Symptoms of systemic congestion:

  • Edema
  • Ab/hepatic pain/swelling
11

Signs of systemic congestion:

  • edema
  • JVD
  • Hepatojugular refluc
  • Hepatic enlargement and tenderness
  • Ascites
  • 3rd heart sound (R sided) -S3 gallop
12

Symptoms of poor perfusion:

  • Extreme fatigue and tiredness
  • Poor appetite
  • Nausea
  • Early satiety
  • Mental status changes
13

Signs of poor perfusion:

  • ↓ BP
  • ↓ CO
  • Worsening renal fxn
  • Cool extremeties
14

T/F: Someone presenting w/ ADHF will have JVD, ascites, and leg edema, while someone presenting w/ CHF will have neck muscle retraction, JVD, air hunger with wide eyes and cyanosis of lips

False

15

In the physical exam, what is being assessed?

  • Vitals
  • Weight
  • Neck
  • Heart sounds
  • Pulmonary exam
  • Abdomen
  • Extremeties
16

Tools for diagnosing ADHF:

  • C-Xray
  • Echocardiogram
  • ECG
17

Which lab values are assessed for ADHF?

  • CBC
  • Electrolytes
  • Renal fxn
  • Cardiac troponin
  • BNP (higher = indicator for HF)
18

An invasive HD monitoring tool that can measure CO:

Swan-Ganz Catheter

19

Normal CI value:

2.2

20

Cardiac index (CI) is indicative of _____________

Perfusion

21

In pts w/ HF, the pulmonary capillary wedge pressure (PCWP) range is:

15-18

22

If PCWP is < 18 in HF pt, how would we describe the pt?

Dry

23

If PCWP is > 18 in HF pt, how would we describe the pt?

Wet

24

If CI is > 2.2, how would we describe the pt?

Warm

25

If CI is < 2.2, how would we describe the pt?

Cold

26

T/F: Invasive hemodynamic monitoring is recommended for all HF pts because they are at high risk for sudden death

False

27

Which subset:

CI >2.2 and PCWP <18

I (warm and dry)

28

Which subset:

CI >2.2 and PCWP >18

II (warm and wet)

29

Which subset:

CI < 2.2 and PCWP <18

III (cold and dry)

30

Which subset:

CI < 2.2 and PCWP >18

IV (cold and wet)

31

Which subset is has the worst outcome?

IV (cold and wet)

32

T/F: Subset I has 2x increased risk in mortality than subset I, and subset IV has a 2.5x increased risk in mortality than subset I.

True

33

Goals of therapy for ADHF:

  • Relieve congestive sx
  • Treat sx of low CO
  • Minimize risks of pharm therapy
  • ID and treat underlying cause
  • Optimize oral therapy prior to discharge
  • Adequate pt education
34

Tx for subset I:

CHF management

  • Maximize oral therapy (especially w/ HFrEF)
  • Monitor
35

T/F: Subset I has the highest mortality

False

36

Tx for subset II:

Need to ↓ pulmonary congestion and maintain CO:

  • IV preload reducers: Loop diuretics, vasodilators (NTG, nitroprusside, nesiritide)
  • Na restriction, supplemental O2 PRN, Fluid restriction
37

First line tx for subset II:

IV loop diuretics

38

If IV loop diuretics are inadequate to relieve congestion (diuretic resistance), what would be the next step?

  • Higher dose of loop diuretic
  • Addition of second diuretic (i.e. metolazone)
  • Continuous infusion of loop diuretic
39

Last line therapy for subset II:

Ultrafiltration

40

T/F: Vasodilators can be used alone or in combo with diuretics in pts with or without hypotension for treating volume overload in subset II

False

41

First line tx for subset III:

  • How dry? If PCWP < 15: IV fluids
  • If PCWP 15 -18: IV positive inotropes
42

Examples of IV positive inotropes:

  • Dobutamine
  • Milrinone
43

Tx for subset IV:

Combo of IV positive inotropes, diuretics, and/or vasodilators

44

List examples of loop diuretics:

  • Furosemide
  • Bumetanide
  • Toresmide
45

T/F: It is recommended to use oral loop diuretics first until volume status is optimized, and then switch to IV

False

46

Loop diuretics improve pulmonary congestion by decreasing _________ (fxnl venodilation, Na and H2O excretion)

Preload

47

Loop diuretic use must be used with caution to avoid:

  • dropping volume too much:
    • ↓ CO
    • Symptomatic ↓ in BP
    • ↓ in renal fxn
48

What is the minimum IV bolus dosing for furosemide?

40 mg

49

If the pt is on furosemide at home, what one time IV bolus would the recieve?

Total home daily dose (max 200 mg)

50

If the pt is not on furosemide at home, what one time IV bolus would the recieve?

  • If SCr <2: 40 mg
  • If SCr >2: 80 mg
51

After the initial IV bolus of furosemide is given, when should urine output be checked?

2h

52

Goal urine output in first 2 hrs if SCr ≤ 2.5

≥ 500 ml

53

Goal urine output in first 2 hrs if SCr > 2.5

≥ 250 ml

54

If pt is not at goal urine output after first 2 hrs, what dose of furosemide should be given?

Double initial dose (given w/in 2-4h of last dose)

55

List reasons for diuretic resistance:

  • ↓ rate of absorption = ↓ peak concentrations = ↓ responsiveness
  • High [Na] reaching distal tubule
  • Low CO, ↓ renal perfusion = ↓ delivery of drug to kidney
56

List second diuretics to add in the case of diuretic resistance:

  • Metolazone
  • Chlorthalidone (IV once daily)
57

Non-pharm therapy for diuretic resistance:

  • Restrict Na and fluid intake
  • Ultrafiltration
58

Monitoring for diuretics:

  • Fluid in/out
  • weight
  • S/sx of congestion
  • Renal fxn (BUN/SCr)
  • Electrolytes (K, Mg, Na)
  • Hemodynamics (BP, HR, PCWP, CI)
59

In the absence of symptomtatic HoTN, _____________ can be added to diuretic therapy for relief of dyspnea in pts w/ acutely decompensated HF

IV vasodilators

60

T/F: Arterial vasodilators ↓ afterload = ↑ CO, while venodilators ↓ preload = ↓ sx of pulmonary congestion.

True

61

Vasodilators should be avoided in SBP < _____ mmHg

90

62

T/F: Vasodilators do not need to be protected from light

False

63

What kind of vasodilator is nitroprusside?

Mixed arterial and venous vasodilator

64

Effects of mixed arterial and venous vasodilators on the body:

  • ↓ SVR
  • ↓ BP
  • ↓PCWP
  • ↑ CO
65

Nitroprusside contraindication:

Low BP

66

Which drug should be considered in pts w/ significantly ↑ SVR?

Nitroprusside

67

T/F: Nitroprusside has a long half life and can be stopped quickly if needed

False

68

Nitroprusside AE:

  • ↓BP, HA, ↑ ICP
  • Thiocyanate toxicity - concern w/ renal impairment
  • Cyanide toxicity - concern w/ liver impairment
69

NTG is what kind of vasodilator?

Mild arterial vasodilator

70

How does NTG affect preload and PCWP?

Decreases

71

AE of NTG:

  • ↓ BP, ↑ HR
  • HA
  • Excessive ↓ PCWP
72

NTG contraindications:

  • ↓ BP
  • Use of PDE-5i
  • Riociguat
  • allergy to corn or corn products
73

T/F: Tolerance may develop to NTG

True

74

____________ is an IV vasodilator that is no longer available in the US

Nesiritide

75

_______________ are recommended in pts w/ severe systolic fxn who present w/ signs of hypoperfusion - to maintain systemic perfusion and preserve end-organ performance

Positive inotropes

76

MOA of positive inotropes:

Enhance contractility by increasing cAMP

77

Examples of positive inotropes:

  • β-agonists (dobutamine, dopamine)
  • PDEi (milrinone)
78

Which class of drug activates adenylate cyclase which catalyzes adenosine triphosphate to increase cAMP?

β-agonists

79

Which class of drug inhibits the breakdown of cAMP?

PDEi

80

T/F: Digoxin is used in the acute management of ADHF

False

81

Dobutamine AE:

  • Tachycardia
  • Arrhythmia risk (ECG)
  • HA
82

This drug has potent inotropic effects (β1) with vasodilating effects as well (β2) and has minimal change on MAP

Dobutamine

83

Why does dobutamine have minimal effects on MAP?

↑ CI and ↓ arteriolar resistance

84

This drug has positive inotropic and arterial and venous vasodilating effects (inodilator). Can either have no change in or decrease MAP and reflex ↑ HR

Milrinone

85

Milrinone AE:

  • Arrhythmias
  • HoTN
  • Thrombocytopenia
  • HA
86

T/F: Milrinone can cause a greater drop in BP than dobutamine

True

87

T/F: Milrinone dose should be reduced in renal impairment (CrCl <50)

True

88

This drug is reserved for marked HoTN or cardiogenic shock

Dopamine

89

Dopamine AE:

  • May ↑ myocardial O2 demand and ↓ myocardial blood flow
  • Arrhythmias
  • ↑ HR
90

List other meds that can be used for ADHF:

  • VTE prophylaxis
  • Vasopressin antagonists
91

When should VTE prophylaxis be used?

pts hospitalized for HF

92

Examples of vasopressin antagonists:

  • Conivaptan (Vaprisol)
  • Tolvaptan (Samsca)
93

When should vasopressin antagonists be used?

pts hospitalized for HF w/ volume overload and persistent severe hyponatremia

94

Monitoring response to therapy should be done how often?

Daily

95

If a pt is on GDMT therapy prior to admission, what should be done?

Continue GDMT in the absence of hemodynamic instability or contraindications

96

If a pt is not on GDMT therapy prior to admission, what should be done?

  • Initiate GDMT prior to hospital discharge
  • Initiate BB after optimization of volume status and successful DC of IV diuretics, vasodilators, and inotropic agents
97

Examples of GDMT:

ARNI, ACEi/ARBs, BB, sprionolactone

98

Discharge counseling for ADHF pts:

  • Diet
  • Discharge meds
  • Daily weight monitoring
  • Activity level
  • FU appts
  • What to do if sx worsen
  • FU clinic visit scheduled usually 7-14 d