Acute Decompensated Heart Failure

Front 1

What are typical hemodynamic values in ADHF

Back 1

MAP 60-80 (80-100)
HR 70-90 (60-80)
CO 2-4 (4-7)
CI 1.3-2 (2.8-3.6)
PWCP 18-30 (8-12)
CVP 6-15 (2-6)

Front 2

How do you treat the subsets of HF

Back 2

Warm and Dry (PCWP 15-18) and CI greater than 2.2
Optimize oral meds

Warm and Wet (PWCP >18, CI greater than 2.2)
IV diuretics and IV vasodilators

Cold and dry
PCWP<15, IVF until PCWP 15-18
PCWP>15 and MAP<50, IV dopamine
PWCP>15, map>50, but hypotensive, use inotrope
PCWP>15, MAP>50, and no hypotension, use arterial vasodilator

Cold and wet
MAP<50, IV dopamine
MAP>50 but hypotensive, inotrope
MAP>50 but not hypotensive, arterial vasodilator

Front 3

How do you treat the chronic HF meds during acute decompensation

Back 3

1) Acute ACEI unless SCr is elevated
2) Continue beta blockers but do not titrate until euvolemic
3) Continue digoxin at 0.5-0.8 unless renal function changes

Front 4

What are the general guidelines for ADHF

Back 4

1) Diuretic therapy for patients with fluid overload. Change to oral when tolerated. May add second type of diuretic if response is minimal
2) Use inotropic therapy to relieve symptoms and improve organ function with hypoperfusion (<CI) and marginal systolic BP or no response to IV dilators

Also consider if patients do not respond to diuretics with fluid overload

3) Vasodilator may be consiudered in addition to loop diuretics in pulmonary edema or hypertension

Should be considered over inotropes for addition to diuretics unless hypotensive

Front 5

When do use inotropic therapy

Back 5

Primarily used to manage hypoperfusion or cold HF. Patients should have adequate filling pressure (PCWP 15-18) before using

Dobutamine is a beta 1 agonist and is a positive inotrope. Use in cold and wet or cold and dry

Can cause arrythmias, tachycardia

Use primarily if hypotensive

2) Milrinone (Primacor)
PDE inhibitor

Can cause hypotension, thrombocytopenia, tachycardia.

Consider if patient on beta blocker

Front 6

When do you use vasodilator therapy

Back 6

Primarily used to manage pulmonary congestion. Venous vasodilation results in decreases in PCWP and acute relief of SOB

Arterial vasodilators (nitroprusside and nesiritide) may be used as alternative to inotropes in low CO and high SVR

1) Sodium nitroprusside
Balanced arterial and venous vasodilator

Warm and wet ADHF, alternative to inotropes in cold and wet adhf

Thiocyanate renally excreted, hypotension

2) Nesiritde - natriuretic peptide

Decreases PCWP and SVR, increases CI

Warm and Wet ADHF, alternative to inotropes in cold and wet ADHF

No renal or hepatic adjustment

Can cause hypotension and tachycardia

3) Nitroglycerin

Preferential venous vasodilator

WARM AND WET ADHF, hypertensive crisis

Hypotension, reflex tachycardia