Term
| What is the origin of ADHF? |
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Definition
- Noncompliance with medication
- Salt/Fluid overload
- Uncontrolled HTN or Afib
- Inappropriate meds: NSAIDS, non-DHP CCBs, Actos, Metformin
- Cardiac event, endocrine diseases |
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Term
| How are ADHF patients assessed? |
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Definition
- Fluid status - Wet or Dry - Orthopnea, Ascites, JVD, pitting edema, Rales
- Perfusion status - Cold or Warm - low BP and cool extremities
- Onset $ Factors |
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Term
| What is a HF patient considered to be decompensated? |
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Definition
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Term
| What lab values lead to a diagnosis and assessment of HF? |
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Definition
- B-type Natriuretic Peptide over 100, will be very high
- Swan-Ganz Catheter measures PCWP, an indicator of fluid status. 15-18 is normal, above 18 is congested
- Cardiac index measures perfusion, Above 2.2 is normal, below 2.2 is hypoperfused.
- Perform invasive monitoring in patients w/ respiratory distress or persistent symptoms |
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Term
| What is Quadrant 1 in the hemodynamics chart? |
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Definition
| Quadrant I - Warm and Dry/best outcome: PCWP is below 18 and CI is Above 2.2. No congestion or hypoperfusion |
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Term
| What is Quadrant 2 in the hemodynamics chart? |
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Definition
| Quadrant 2 - Warm and wet - CI is above 2.2 but PCWP is over 18, indicating fluid overload |
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Term
| What is Quadrant 3 in the hemodynamics chart? |
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Definition
| Quadrant 3 - Cold and dry: CI is below 2.2 while PCWP is below 18, indicating hypoperfusion. |
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Term
| What is Quadrant 4 in the hemodynamics chart? |
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Definition
| Quadrant 4 - Cold and wet/worst outcome: CI is below 2.2 and PCWP is above 18, indicating hypoperfusion and fluid overload |
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Term
| How is Quadrant 1 (Warm and dry) treated? |
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Definition
| Optimize their oral therapies to target dose ranges for CHF, make sure they are on Lasix, an AceI, and a BB. |
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Term
| How do you treat Quadrant 2 (Warm and Wet)? |
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Definition
Maintain cardiac output with oxygen
Restrict fluid and salt
use IV preload reducers:
Loop diuretics (first) --> Vasodilators (second) - NTG/Nitroprusside/Nesitiride
- Continuous infusion of Lasix, may add 2nd diuretic (Metolazone), may add vasodilator if no hypotension exists |
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Term
| How is Quadrant 3 (Cold and dry) treated? |
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Definition
- Maintain fluid status at 15-18, may give IV fluids
- Give IV positive inotropes (Dobutamine, milrinone) or possibly vasodilators to increase CO |
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Term
| How is Quadrant 4 (Cold and Wet) treated? |
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Definition
- Give positive inotropes to increase CO/CI FIRST, if this does not work, give vasodilators, then diuretics.
- Give Diuretics and vasodilators to decrease PCWP and fluid overload
- Careful monitoring, most severe state |
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Term
| How do diuretics work and how are they dosed? |
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Definition
- Reduce preload by promoting Na/H2O excretion
- Identify total home dose, give that dose as a bolus (max 180 mg). If not on home dose, give 40 mg IVP if SCr <2 and 80 mg IVP if SCr > 2
- Check urine output at 2 hours, goal is 500 mL (250 mL if SCr >2.5). If not at goal output, DOUBLE initial bolus |
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Term
| How can diuretic resistance be overcome? |
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Definition
- Higher bolus and continuous infusion of Lasix
- Addition of Metolazone, Chlorthiazide, or Spironolactone
- Last line: Ultrafiltration |
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Term
| When should vasodilators NOT be used? |
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Definition
| When systolic blood pressure is less than 90. |
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Term
| What drugs are vasodilators and how do they work? |
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Definition
Reduce preload and afterload
- Nitroprusside - use in patients with very high SVR, watch cyanide toxicity
- Nitroglycerine - milder vasodilator, can develop tolerance
- Nesiritide - Venodilator, coming off formulary
- may be ADDED to wet patients where diuretics are not working |
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Term
| What drugs are positive inotropes and how do they work? |
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Definition
- increase cAMP levels, either beta agonists or PDE-3 inhibitors
- Dobutamine - beta-agonist, helps in hypoperfusion and hypotension, DOES NOT WORK with beta-blockers --> use milrinone
- Milrinone - PDE-3 inhibitor, more significant side effects. Do not use in low BP, use Dobutamine
- Dopamine - Beta agonist, use only in drastic hypotension/shock |
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Term
| How should CHF medications be handled while in ADHF? |
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Definition
- Continue AceI therapy in the absence of contraindications
- Resume beta blocked ONLY when stable, fluid status and BP optimized |
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Term
| In summary, how do you treat each quadrant of ADHF? |
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Definition
I – Warm and Dry – AceI/ARB, BB, Loop
II – Warm and Wet – Loop Diuretics and Vasodilators, no inotropes
III – Cold and Dry – Inotropes, fluids to get to goal. + or – vasodilators depending on SBP and PCWP
IV – Cold and Wet – Loop diuretics, Inotropes, Vasodilators |
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